**Rehabilitation Services A dministration**  **An nual**  **Progress Report**  **for State Grant** **s for A** 

**ssistive Technology Public Reporting Burden**  OMB # 1820 - 0572 Expires: Paperwork Burden Statement According to the Paperwork Reduction Act of 1995, no persons are requ ired to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 402 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required under the Assistive Technology Act of 1998 , as amended to reta in benefit of the State Grant for Assistive Technology Program. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Mary land Ave., SW , W ashington, DC 20210 -4537 or email ICDocketMgr@ed.gov and reference the OMB Control Number 1820 - 0572. **This document was prepared by the**  **Center for A ssistive**  **Technology Ac**  **t Data As**  **sistance under**  **Gran t**  **No. H224B110002 from the U.S. Department of Education** **Table of Contents**

General Information

................................ ................................ ................................ ......... 1 State Financing

................................ ................................ ................................ ............... 2 Reu se ................................ ................................ ................................ ............................ 18 Device Loans

................................ ................................ ................................ ................ 2 1 Device Demonstrations

................................ ................................ ................................ . 2 6 Overall Performance Measures

................................ ................................ ..................... 30 Training

................................ ................................ ................................ ......................... 3 1 Technical Assistance

................................ ................................ ................................ ..... 3 5 Public Awareness and Information and Assistance

................................ ....................... 3 8 State Improvement Outcome s ................................ ................................ ....................... 40 Additional and Leveraged Funds

................................ ................................ ................... 4 1 Data Collection Instrument Access Performance Measure

................................ ........... 4 3 Data Collection Instrument Acquisition Performance Measure

................................ ..... 4 4 Data Collection Instrument IT/Telecommunications Training Performance Measure

.... 4 6 Survey Instrument Customer Satisfaction

................................ ................................ ..... 4 7

Instructions for completion of this form and rele vant definitions are contained in a separate document, “ **Instruction Manual and Definitions for the Annual Progress**  **Report for State Grant s**  **for Assistive Technology.”**Page 1 

### General Information **1. General Information Statewide A** 

**T Program** 1. State and Progra m Title **Lead A gency**  2. Agency name 3. Mailing address 8. Fax 4. City 9. Program URL 5. State 10. Program E - mail 6. Zip code 11. Program toll -free number  Check if in state only 7. Phone 12. Program TTY number **Implementing Entity** 13. Check here if not applicable. If applicable, complete Items 14

– 24. 14. Name of implementing entity 15. Mailing address 20. Fax 16. City 21. Program URL 17. State 22. Program E - mail 18. Zip code 23 . Program toll -free number  Check if in state only 19. Phone 24 . Program TTY number **Program director and other contacts** 25. Program Director at Lead Agency (last, first) 26. Titl e 27. Phone 28. E - mail 29. Name of Program Director at Implementing Entity (last, first)

– If a pplicable 30. Title 31. Phone 32. E - mail **Person Responsible for completing this form is other than Program Director** 33. Name (last, first) 34. Title 35. Phone 36. E - mail **Certifying Representative** 38. Name (last, first) 39. Title 40

. Phone 41. E - mail**State Financing**

Page 2 

### State Financing Outline Overview of Activities Performed A. Financial loan programs 1. Loan applications 2. Income of applicants to whom loans were made 3. Loan type 4. Interest rates 5. Types and dollar amounts of AT financed 6. Defaults 7. Additional Data for Title III Funded AFP B. State financing activities that provide consumers with resources and services that result in the acquisition of AT devices and services 1. Overview of Activities Performed 2. Geographic Distributio n, Number of Individuals W ho Acquired AT Devices and Services and Number for whom Performance Measure Data are Collected 3. Types and dollar amounts of AT funded C. State financing activities that allow consumers to obtain AT at a reduced cost 1. Overvi ew

of Activities Performed 2. Geographic Distribution and Number of Individuals Served 3. Savings to consumers, by type of AT device/service D. Anecdote E. Performance measures F. Customer S atisfaction G. Notes Section 4f requirements: (1) the type o f State financing activities...used by the State; (2) the amount and type of assistance, including the number of applications for assistance received, the number of applications approved and rejected, the default rate for the financing activities, range and average interest rate for the financing activities, range and average income of approved applicants for the financing activities, and the types and dol lar amounts of AT financed; (3) consumers of the State financing activities, who shall be classified by t

ype of AT device or service and geographical distribution A state financing activity is an activity approved as part of your State Plan for AT, such as the development of systems: to provide and pay for AT, for the purchase, lease, or other acquisition of, or payment for AT; or of State -fi nanced or privately financed alternative financing systems of subsidies. Examples of state financing activities include, but are not limited to administering financial loan programs, administering “last resort” activit ies funded with non -AT Act**State Financing**

Page 3 dollars, administering cooperative buying programs, administering telecommunications distribution programs, and other activities designed to provide consumers with resources and services that result in the acquisition of AT devic es and services. **Overview of**  **Ac tiv**  **ities Performed** Did your approved State Plan for this reporting period include conducting any State Financing activities?

– check yes or leave unchecked. If yes complete one or more of sections A, B, or C

. **A. Financial Lo**  **an Programs** Did your approved State Plan include conducting a financial loan program? (Do not include Access to Telework in this report. )

– check yes or leave unchecked. If yes -- is this financial loan program a Title II Alternative Financing Program?

– check yes or leave unchecked. If only the first question is checked yes, Items 1 - 6 of Section A will be completed. If both questions are answered yes, Item 7 of Section A will also be completed. **1. Loan A**  **pplications** In this section, report on: (1) revolv ing loans that are made directly by the Statewide AT Program; and (2) partnership loans that use dollars from another source, usually a financial institution, in which the statewide AT program has an investment through loan guarantee, agreement with a fina ncial institution based on an investment deposit, interest or principal buy- dow n, or other financial or administrative role

. Do not include loans in which the statewide AT program had no financial or administrative role, such as loans for which you simply made a referral to a lending source. In the table below, report information on loan applications made by Rural Urban Continuum Code (RUCC) of the applicant’s county of residence and the decisions made about those applications. Include all applications t hat were processed to one of the three decisions shown in the table below (i.e., approved

— loan not made, approved

— loan made, or rejected) during this reporting period, even if the application was received prior to the start of the reporting period. Do not include applications that were not reviewed because they were not complete, were withdrawn before a final decision was made, or were still pending at the end of the reporting period. For guidance on how to classify the applicant’s area of residence as me tro or non - metro, please see the “General Instructions.”**State Financing**

Page 4 **Number of A pplications**  **Ar ea of Residence**  **Total Metro**  **RUCC 1 -**  **3 Non**  **- Metro** 

**RUCC 4 -** **9** A. Approved

— loan made System generated B. Approved

— loan not made (i.e., the application was withdrawn after the loa n was approved, or the loan was approved but not accepted by the consumer) System generated C. Rejected System generated D. Total System generated System generated System generated **Income of Applicants to Whom Loans Were Made** This section collects data about the income of applicants to whom loans were made (i.e., those who were counted in row A of the table in Section B, Item 1above). For purposes of this section, the income of these applicants is the gross annual income that the applicants reported on the loan applications (i.e., the amount upon which the decision about the loan was based). This may be the income of the individual, the family, and/or one or more co - borrowers. a. Enter the lowest and highest income reported among all applicants to whom l oans were made during the reporting period: Lowest: $______________ Highest: $______________ b. Use the table below to calculate the average gross annual income of applicants to whom loans were made. In Column A, enter the sum of the incomes reported by all applicants to whom loans were made. The system will divide that amount by the number of applicants to whom loans were made (as reported in row A of the table in Section B, Item 1 above to calculate the average income. **A B**  **C Sum of**  **Incomes Number of A**  **pp licants to Whom** 

**Loans Were Made Average Gross**  **An nual Income**  $ System -generated System -generated c. In the table below, enter the number of loans made to applicants who reported incomes in each of the specified ranges. The total number of loans should matc h the number you reported in row A of the table in Section B, Item 1**State Financing**

Page 5 above. The system will calculate the percentage of loans made to individuals in each income category. **Number and Percentage of Loans Made to A** **pplicants with Incomes of Total**  **$15,000 or Less**  **$15,001**

**to $**  **30 ,000**  **$ 30**  **,001**

**to $**  **4 5,000**  **$ 4**  **5 ,001** 

**to $**  **60 ,000**  **$ 60**  **,001**

**to $**  **7 5,000**  **$ 7**  **5,001**

**or More** Number of loans System

- genera ted Percentage of loans System generated System generated System generated System generated System generated System g enerated System

- genera ted (System will generate an error message if total number of loans does not match number reported in row A of the table in Section A .1. ) **2. Loan Type**  **a )**  Enter the number of partnership loans by loan type. Any row left blank will au tomatically count the number of loans as zero. The system will calculate the percentage of loans that fall into each category. For guidance on how to categorize partnership loans, refer to the instructions. Report each loan in only one category.

**Ty pe o**  **f Loan Number**  **of Loans Percentage** 

**of Loans Revolving Loan**  **- Low Interest (prime or less)**  System generated **Revolving Loan –**  **Preferred Interest (greater than prime)**  System generated **Low interest (prime or less)**  Wi thout interest buy- down or loan guarantee System generated Wi thout interest buy- down only System generated Wi th loan guarantee only System generated Wi th both interest buy- down and loan guarantee System generated **Preferred interest (greater than prime)** Wi thou t interest buy- down or loan guarantee System generated Wi thout interest buy- down only System generated Wi th loan guarantee only System -**State Financing**

Page 6 generated Wi th both interest buy- down and loan guarantee System generated **Total** System generated S

ystem generated (System will generate an error message if total number of loans does not match number reported in row A of the table in Section A.1. ) **b )**  Enter the dollar value of both partnership loans and revolving loans. The number of loans in each c ategory will automatically populate based on the table in 3(a). Report each loan in only one category. **Ty pe of Loan**  **Number of Loans Dollar Value of Loans**  Revolving loans System -generated $ Partnership loans System -generated $ Total System -generated S ystem -generated **3. Interest Rates**  **a )**  Enter the lowest and highest interest rates among all loans made, including both revolving and partnership loans. For interest buy- downs, report the interest rate to which you bought the loan down:

Lowest:

___________

___% Highest: ______________% **b)** Use the table below to calculate the average interest rate for all loans, including both revolving and partnership loans. Enter the sum of interest rates for all loans in Column A. The system will divide that amount by the number of loans made as previously reported and automatically populated in row A to calculate the average interest rate.

**A B**  **C Sum of**  **Interest Rates**  **Number of Loans Made Average**  **Interest Rate** System -generated System -generated**State Financing**

Page 7 **c)** In the table bel ow, enter the number of loans made at interest rates in each of the specified ranges. The total number of loans should match the number you reported in row A of the table in Section A.1. above

.

**Number of Loans Made at Interest Rates of --**  **Total Number o**  **f Loans 0**  **- 2.0%**  **2.1 –**  **4.0% 4.1**  **–**

**6.0% 6.1**  **–**

**8.0% 8.1**  **-**

**10% 10.1**  **-**

**12% 12.1**  **-**

**14% 14+%**  System generated (System will generate an error message if total number of loans does not match number automatically populated as the total based on previous reported data .) **4. Types and Dollar Amounts of AT Financed**  Use the table below to provide information on the types of devices or services financed and the dollar value of loans made for each type of device or service. Report device s/service s only on c e in a category per loan . For guidance on how to classify devices and services, and decision rules for devices and services that could be classified in more than one way, refer to the General Instructions. Because a single loan may pay for more than one device or service, the number of devices and services reported in this table may exceed the number of loans. However, the total dollar value of loans should be the same as reported previously in 3.b. For large building access projects or similar activities with multiple de vices in one AT category , the numbers reported should reflect a logical access grouping (e.g., a bathroom modification or exterior ramping of a house would be a home modification). Wh ere an AT service (such as an evaluation) was part of a financial loan, include that dollar amount in the appropriate AT category associated with the service (e.g., an audiological evaluation would go in the “hearing” category). If the loan is a refinance , and the AT purchased with previous loan has never been reported, you s hould reported the AT devices/services purchased with the previous loan as the AT associated with the refinance

. (NOTE: If the refinance is of a previous loan and the AT purchased with the previous loan has been reported , the refinance should not be repo rted at all

. )

. **Ty pe of**  **AT Dev**  **ice/Service Number of Devices**  **Financed Dollar Value**  **of Loans**  Vision Hearing Speech communication Learning, cognition, and developmental Mobility, seating and positioning**State Financing**

Page 8 Daily living Environmental adapt ations Vehicle modification and transportation Computers and related Recreation, sports, and leisure **Total** System -generated $ System -generated (System will generate an error message if total dollar value of loans does not match amount reported in the Total Dollar Value of Revolving Loans and Partnership Loans calculated in Item 3(b) above.) **6. Defaults** In the first cell below, enter the numbe r of loans that were in default during this reporting period. A loan is in default after 120 days i n which the borrower has not made the schedule d payment for the balance still owed; or at which time the organization administering the loan paid the lending institution the remaining agreed upon balance of loan. Do not count any payments that may have bee n made by the loan administering organization on behalf of the borrower during that 120 - day period as payments made by the borrower. (Rescue payments do not count as borrower payments and the 120 day clock continues). In the second cell below enter the ne t dollar loss on defaulted loans

. Net dollar loss on loans means the amount lost as a result of default during this reporting period after subtracting any funds that were recovered. It includes the amount that is unpaid on any loans in default and any lo an guarantee payout amounts minus the amount of collateral recovered.**State Financing**

Page 9 **Number of Loans in Default Net Dollar Loss on Loans**  Note: If you have a loan in default for this reporting period and you reasonably believe you will be able to recoup some of the net dollar loss associated with this default during the next reporting period you can choose to defer reporting the default and the net dollar loss until the next reporting period. This should only occur when loans went into default later in the curre nt reporting period and you have not had sufficient time to sell or otherwise recoup some of the value of the collateral. **7. Additional Data for**  **Title III funded AFP** This section collects additional d ata ONLY for financial loan s that are part of a Title III funded Alternative Financing Program (AFP). By completing this section you will NOT need to submit these loans in the separate AFP Progress Report. **a) Range of Dollar Amounts of Loans Provided**  In the table below, enter how many loans were made wit hin the range of dollar amounts shown below. This is the dollar amount of the entire loan, not the dollar amount divided among different devices if more than one device was purchased.

(System will generate an error message if total number of loans does not match number reported in row A of the table in Section A.1 .) **b) Highest and Lowest Loan A**  **mounts** Enter the highest and lowest actual dollar amounts of loans provided during this reporting period: Highest $_________ Lowest $ _________ **c) Classification of Consumers Receiving A** **ssistance Number and Percentage of Loans**  **Ma de to A** **pplicants in the A mount of**  **$1,000 or**  **Less $1,001** 

**to $5,000**  **$5,001**

**to $10,000**  **$10,001**

**to $15,000**  **$15,001**

**to $20,000**  **$20,001**

**to $25,000**  **$25,001**

**to $50,000**  **$50,001**

**or More Total**  **Number of**  **loans** System generated **Percent of**  **Loans** System generated System gener ated System generated System generated System generated System generated System generated System generated System generated**State Financing**

Page 10 Use the tables below to report d ata about the consumers who received loans from your Title III funded alternative financing program (AFP) during this reporting period. The data should be provided only for the direct user of the AT, not the individual to whom the loan was provide d (in some cases these are the same person, but often they are not). A direct user is an individual that uses an AT Device or Service that provides a direct benefit or impact to the individual. A secondary user or beneficiary is a person who benefits from the user having an AT Device or Service. For example, if a family acquired a modified van for two children that are wheelchair users, both children would be considered direct users, but the parents of the children would be considered the secondary users o r beneficiaries. Although a secondary user or beneficiary may benefit from the direct user having an AT device or service, for the data below, you must report on the direct user only. **i )**  **Gender** Enter the total number of direct users of AT benef iting from a loan for a device or service by gender - female or male. If multiple persons are direct users of the AT provided by a single loan, the gender for each direct user should be reported. **Gender of Direct User(s) Number**  Female Male Total System -gener ated (Total must be equal to or greater than Row A of the table in Section A.1

– total loans made.) **ii )**  **Ag e**  Enter the total number of direct users of AT benefiting from a loan for a device or service by the age range distribution. If multiple persons are direct users of the AT provided by a single loan, the age for each direct user should be reported. Programs should report the actual age of the direct user(s) at the time the loan was made. **Ag e of**  **Direct Users of A** **T Number**  0 - 9 10 - 17 18 - 29 30 - 3 9 40 -49 50 - 59 60 - 69 70 - 79 80+ Total System -generated (Total must equal total in i. above.)**State Financing**

Page 11 **iii )**  **Ty pe of Disability**  In this section, report on the AT user’s abilities affected by the AT they are purchasing during this reporting period. An AT user may be affected in more than one area, therefore the data reported for each user may reflect multiple areas or “Type of Abilities” affected.

**Ty pe of**  **Ab ility**  **Number** Seeing Hearing Talking/communicating Getting around/mobility Handling obj ects, reaching Learning new information Remembering Interacting with others/socializing **Total** System -generated ( Total must be equal to or greater than i. and ii. The number of areas affected may exceed the totals reported for age and gender. ) **B. St**  **ate Financing A ctivities that Provide Consumers with resources and**  **services that result in the acquisition of A** **T devices and services 1.**  **Overview of Activities Performed** How many other state financing activities that provide consumers with access to funds for the purchase of AT devices and services were include d in your approved State Plan?

– enter number

. Which of the following best describes this state financing activity? Drop - down box: ( 1)“last resort” activity; ( 2 ) telecommunications distribution; ( 3 ) other (specify) **2. Geographic Distribution, Number of Individuals Who Acquired AT Devices and**  **Services and Number for whom Performance Measure Data are Collected** In this table, report the number of individuals who acquired AT devices and services through this activity, by the Rural Urban Continuum Code (RUCC) for the county in which they reside. For guidance on how to find a county’s RUCC, please see the “General Instructions.” Of the recipients of AT devices and service, identify the number for whom per formance measure data can be reported. This may be all of the recipients or may be fewer if the Statewide AT Program is administering a program (using external funding to purchase/provide the AT) on behalf of an entity that has responsibility for providin g AT devices and services. The performance measure data questions are not answerable by such entities. W hile the number of individuals served by such programs should be reported here and in #3 below, performance measure data should not be collected for t hose individuals.**State Financing**

Page 12 **County of Residence Individuals**  **Served** A.Metro (RUCC 1 - 3) B.Non - Metro (RUCC 4 - 9) **C. Total Served**  i System generated **D. Excluded from Performance Measure (** Number of individuals excluded from performance measure data collection beca use AT is provided to or on behalf o f an entity that has an obligation to provide the AT such as schools under IDEA or VR agencies/clients) Mandatory explanation **E. Number of Individuals Included in Performance Measures** ii System generated (ii = i mi nus excluded number D ) If a number is reported in D you must provide a description of the reason the individuals are excluded from the performance measure:

_________________________________________ **3. Types and Dollar Amounts of AT Funded**  Use the table below to provide information on the number of devices or services funded and the amount of funding provided, by type of AT device/service. Report each device or service in only one category. For guidance on how to classify devices and services, and decision r ules for devices and services that could be classified in more than one wa y, refer to the General Instructions. For large building access projects, the numbers reported should reflect a logical access grouping (e.g., a bathroom modification or exterior ra mping of a house would each be one home modification). Wh ere funding was provided for an AT service (such as an evaluation), include that dollar amount in the appropriate AT category associated with the service (e.g., an audiological evaluation would go i n the “hearing” category). **Ty pe of**  **AT Dev**  **ice/Service Number of Devices**  **Funded Value of A**  **T Provided**  Vision $ Hearing $ Speech communication $ Learning, cognition, and developmental $ Mobility, seating and positioning equipment $ Daily livin g $ Environmental adaptations $ Vehicle modification and transportation $**State Financing**

Page 13 Computers and related $ Recreation, sports, and leisure $ **Total** System -generated $ System -generated **C. State Financing A** **ctivities that A llow Consumers to Obtain A**  **T at Red uced**  **Cost 1.**  **Overview of Activities Performed** How many activities that allow consumers to obtain AT at reduced cost were included in your approved State Plan?

– enter number. W hich of the following best describes this state financing activity? Drop - down b ox: (1) cooperative buying activity; (2) other (specify) **2. Geographic Distribution and Number of Individuals Served**  In this table, report the number of individuals who acquired AT devices and services through this activity, by the Rural Urban Continuum Co de (RUCC) for the county in which they reside. For guidance on how to find a county’s RUCC, please see the “General Instructions.” Of the recipients of AT devices and service, identify the number for whom performance measure data can be reported. This m ay be all of the recipients or may be fewer if the recipients of the cost savings are entities that have responsibility for providing AT devices and services regardless of cost. The performance measure data questions are not answerable by such entities. Wh ile the number of individuals served by such programs should be reported here and in #3 below, performance measure data should not be collected for those individuals. See the instructions “Wh o To Collect Data ” for more information. **County of Residence Number of**  **Individuals Served**  A.Metro (RUCC 1 - 3) B.Non - Metro (RUCC 4 - 9) **C. Total Served** i System generated **D. Excluded from Performance Measure (** Number of individuals excluded from performance measure data collection because AT is provided to or on b ehalf of an entity that has an obligation to provide the AT such as schools under IDEA or VR agencies/clients) Mandatory explanation **E. Number of Individuals Included in Performance Measures** ii System generated (ii = i minus excluded number D. )**State Financing**

Page 14 If a num ber is reported in D you must provide a description of the reason the individuals are excluded from the performance measure:

_________________________________________ **3. Savings to Consumers, by Type of AT Device/Service**  Use the table below to provide info rmation on the number of devices or services provided to consumers and the savings to consumers resulting from this activity, by type of AT device or service. Report each device or service in only one category. For guidance on how to classify devices and services, and decision rules for devices and services that could be classified in more than one way, refer to the General Instructions. For each type of AT device, enter the total estimated current purchase price of the devices and the total amount for w hich devices were sold. The system will calculate the resulting savings to consumers. Use the Manufacturer’s Suggested Retail Price (MSRP) to determine the current purchase price of the device. If you are unable to find the exact price for a particular item, use the value of a comparable device. Using estimates is acceptable when exact pricing is not available. You may need to identify multiple similar devices and average to estimate a MSRP. If the device was given away, use a sale price of zero in yo ur calculations. For large building access projects, the numbers reported should reflect a logical access grouping (e.g., a bathroom modification or exterior ramping of a house would each be one home modification). Wh ere funding was provided for an AT se rvice (such as an evaluation), include that dollar amount in the appropriate AT category associated with the service (e.g., an audiological evaluation would go in the “hearing” category). **Ty pe of**  **AT Device/Service**  **Number Provided**  **Total**

**Estimated Current R** **etail Purchase Price**  **Total Price**

**for Which Devices**  **Were Sold Savings** 

**to Consumers** Vision System generated Hearing System generated Speech communication System generated Learning, cognition, and developmental System generated Mobility, seating and positioning System generated Daily living System generated Environmental adaptations System generated**State Financing**

Page 15 Vehicle modification and transportation System generated Computers and related System generated Recreation, sports, and leisure System generated **Total** System generated System generated System generated System generated **D. An**  **ecdote** Provide at least ONE anecdote about an individual who benefited f rom a state financing activity. Do not provide more than TWOanecdote s. If you have a picture to accompany the narrative you submit, please check the box provided. If you reported Title III AFP financial loan data in section A, you MUST provide an anecdote here for that activity. You may provide an additional anecdote if you reported an activity in section B and/or C. Each narrative is limited to 1000 words for purposes of the MIS data system. Wh ile you can enter words past this limit, they will not be displayed when data is pulled from MIS. If you have a picture to ac company anecdote #1, please check here (Narrative item #1) If you have a picture to accompany anecdote #2, please check here (Narrative item #2

) **E. Performance Measures**  State financing activities are covered by the Acquisition Performance Measure. To collect data for this measure, statewide AT programs will collect follow - up information from consumers. Use data collected from consumers to complete the table below. Refer to the “General Instructions” for guidance on how to categorize the primary purpose for which AT devices/service are needed. The total number of customers from whom data is repo rted must equal the sum of the number of individuals to whom financial loans were made ( as reported in Section A .1.A ) and the number of individuals served by other state financing activities who are included in performance measures ( as reported in Sections B .2. E .ii and C .2. E .ii )

.**State Financing**

Page 16 **Response Primary**  **Purpose for Which A T is Needed**  **Total Education**  **Employ ment**  **Community Living**  1. Could only afford the AT through the statewide AT program (n,d) 2. AT was only available through the statewide AT program (n,d) 3. AT was available through other programs, but the system was too complex or the wait time was too long (n,d) 4. Subtotal System generated System generated System generated 5. None of the above (d) 6. Subtotal System generated System generated System generated 7. Nonrespondent (d) 8. Total System generated System generated System generated System generated 9. Performance on this measure System generated System generated System generated NOTES: Items marked (n) are included in numerator. Items marked (d) are included in denominator. Non - respondents are included in denominator. (System will generate an error message if total reported in column at far right does not equal total of Sections A .1.A plus B .2. E.ii plus C .2. E.ii ) **F. Customer Satisfaction**  Use data from customer surveys (which include an item about satisfaction) to complete the table below for all customers served by state financing activities. **Customer Rating of Services Number of Customers**  **Percent** Highly satisfied System -generated Satisfied System -generated Satisfied somewhat System -generated Not at all satisfied Syste m -generated Nonrespondent System -generated **Total** System -generated **Response rate** System -generated (System will generate an error message if total does not equal total reported in Sections A.1.A plus B.2.C.i plus C.2.C.i.)**State Financing**

Page 17 **G. Notes** Describe any uni que issues that may affect your data in this section (e.g., types of devices/services that may not be financed because they are financed by other programs). (Narrative item)Page 18 

### Reu **se Outline**  Overview of Activities Performed A. Number of recipients of reu sed devices B. Device exchange activities C. Device Reassignment/Refurbishment and Repair Activities D. Open - ended loans E. Anecdote F. Performance measures G. Customer satisfaction H. Notes Section 4f requirement: the number, type, estimated value, and scope of assistive te chnology devices exchanged, repaired, recycled, or reutilized (including redistributed through device sales, loans, rentals, or donations) through the device reutilization activities, and an analysis of the individuals with disabilities that have benefited from the device reutilization activities Device reu se includes device exchange activities and device re assignment/refurbish ment and repair activities. It also includes open - ended device loans in which the borrower can keep the device for as long as it is needed, because these loans are considered a form of “acquisition.” Device exchange activities are those in which devices are listed in a “want ad” - type posting and consumers can contact and arrange to obtain the device (either by purchasing it or obta ining it for free) from the current owner. Exchange activities do not involve warehousing inventory and do not include sanitation or refurbishing of used devices. In some cases, a Statewide AT Program serves as an intermediary directly involved in making this exchange ; in others the consumer and current owner make this exchange without the involvement of the Statewide AT Program. Data on device exchange may be difficult to gather if your program does not serve as an intermediary directly involved in the e xchange. Device re assignment/refurbish ment and repair activities are those in which devices are accepted (usually by donation) into an inventory; are sanitized and/or refurbished as needed; and then offered for sale, loan, rental, or give away to consumers as re distributed products. Repair activities are those in which device ( s ) are repaired for an individual (without the ownership of the device changing hands) which prevent the owner from needing to purchase a device. Open - ended device loans are when a device borrower can keep a device (usually a reused device) for as long as required to meet a particular need. Open - ended device loans are generally distinguishable from short- term device loans by the length of the**Reuse**

Page 19 typical loan period. Open - ended loans a re generally long term with the device placed with a consumer on a permanent basis but done via loan rather than ownership transferring to the consumer. **Overview of A** **ctiv ities Performed**  Did your approved State Plan for this reporting period include condu ct ing any device reu se activities ? Check yes or leave unchecked. **A. Number of Recipients of Reu**  **sed Devices**  In this table, report the number of recipients of devices through device exchange, re assignment/refurbishment and repair activities, and open - ende d loans. In the table below, report on the number of individuals who receive devices through a reu se program. Recipients should be reported only once, even if they receive multiple devices during this reporting period. (The multiple devices will be repo rted in subsequent sections.) There are two reasons that individuals may be excluded from the Performance Measures

– (1) Given the fact that many device exchange programs have little direct contact with device buyers, it may not be possible to collect inform ation sufficient to include these individuals in the performance measures. Therefore, you can choose to exclude exchange device recipients from performance measure data reporting simply because you are unable to or it is too difficult to collect such data . Exchange is the only activity that offers this opt - out option for performance measure data. (2) Some entities that have an obligation to provide AT may provide it via reu se . For example, a school has an obligation to provide AT device s identified in a n IE P and the school may obtain the device through the reu se program. In th is case, the performance measure questions are not answerable by the school because the issue s of affordability or availability are not allowable reasons to limit access to AT that has been identified as necessary by the IEP team. You should exclude from the performance measures device recipients who acquire reu sed devices under these circumstances.

**Ac tiv**  **ity Number of Individuals**  **Receiving a Device from Ac**  **tiv ity**  A. Device exchange B. Re assignment/refurbishment and R epair C. Open - ended loans **D. Total**  **Served** i System -generated

**Performance Measure** E. Device Exchange - Excluded from Performance Measure F. Re assignment/refurbishment and R epair and Open - Mandatory explanation**Reuse**

Page 20 ended loans

– Excluded from Performance Measure because AT is provided to or on behalf o f an entity that has an obligation to provide the AT such as schools under IDEA or VR agencies/clients) **G. Number of Individuals Included in Performance Measures**  ii Sys tem -generated (ii = i minus sum of excluded numbers, E + F ) If a number is reported in F you must provide a description of the reason the individuals are excluded from the performance measure:

_________________________________________ **B. Device Exchang e**  **Ac tivities**  Enter the total number of devices exchanged (listed by one individual/entity and obtained by another) during the reporting period, by AT type. For each type of AT device, enter the total estimated current purchase price of the devices and th e total amount for which the devices were exchanged. To report a device as “exchanged” you must have documentation of the price for which it was sold or exchanged. Use the Manufacturer’s Suggested Retail Price (MSRP) to determine the current purchase pri ce of the device. If you are unable to find the exact price for a particular item, use the value of a comparable device. You many need to identify multiple similar products and average to identify a MSRP. Using estimates is acceptable when exact pricing information is not available. If the device was given away, use a sale price of zero in your calculations. The system will calculate the resulting savings to consumers in the last column. **Ty pe of**  **AT Dev**  **ice Number of**  **Devices Exchanged**  **Total**

**Estimated Cu**  **rrent Purchase Price**  **Total Price**

**for Which Device(s)**  **Were Exchanged**  **Savings to**

**Consumers** Vision System generated Hearing System generated Speech communication System generated Learning, cognition & developmental System generated Mobili ty, seating and positioning System generated Daily living System generated**Reuse**

Page 21 Environmental adaptations System generated Vehicle modification & transportation System generated Computers and related System generated Recreation, sports and leisure System generated **Total** System generated System generated System generated System generated **C. Device Re**  **assignment /Refurbishment**  **and Repair A** **ctiv ities**  Enter the total number of devices re assigned /refurbished / repaired and acquired by an e nd user during the reporting period, by type. For each type of AT device acquired, enter the total estimated current purchase price of the devices and the total price for which the devices were sold. The system will calculate the resulting savings to con sumers. Use the MSRP to determine the current purchase price of the device. If you are unable to find the exact price for a particular item, use the value of a comparable device. Yo u many need to identify multiple similar products and average to identif y a MSRP. Using estimates is acceptable when exact pricing information is not available. If the device was given away, use a sale price of zero in your calculations. **Ty pe of**  **AT Dev**  **ice Number of**  **Devices Re**  **assigned /**  **Refurbished &**  **Repaired Total** 

**Estimated Current**  **Purchase Price**  **Total**

**Price for Which**  **Devices Were Sold**  **Savings to**

**Consumers** Vision System generated Hearing System generated Speech communication System generated Learning, cognition and developmental System generated Mobility , seating & positioning System generated Daily living System generated Environmental adaptations System generated**Reuse**

Page 22 Vehicle modification & transportation System generated Computers and related System generated Recreation, sports and l eisure System generated **Total** System -generated System generated System generated System generated **D. O**  **pen Ended Loans** Enter the total number of devices loaned in open - ended loans during the reporting period, by type. Fo r each AT type , enter the tot al estimated current purchase price of the devices and the cost to the consumer for the loan. If there was no charge to the consumer, use a zero as the cost to the consumer. The system will calculate the resulting savings to consumers. Use the MSRP as th e current purchase price of the device. If you are unable to find the exact MSRP for a n item, use a comparable device price

. You may need to identify multiple similar products and average for the MSRP. Using estimates is acceptable when exact pricing in formation is not available. NOTE: Open - ended loans are reported only once in the reporting period the loan is made; not in subsequent years e ven if the loan is still open. **Ty pe of**  **AT Dev**  **ice Number of**  **Devices on Long**  **- Term**  **Loan Total** 

**Estimated Current**  **Pur chase**  **Price Cost to** 

**Consumer for the**  **Loan Savings to** 

**Consumers** Vision System generated Hearing System generated Speech communication System generated Learning, cognition and developmental System generated Mobility, seating and positio ning System generated Daily living System generated Environmental adaptations System generated Vehicle modification & System -**Reuse**

Page 23 transportation generated Computers and related System generated Recreation, sports and leisure System ge nerated **Total** System generated System generated System generated System generated **E. An**  **ecdote** Provide ONE anecdote about an individual who benefited from a reu se activity. For guidance on information to include in the anecdote, please see the “Genera l Instructions.” If you have a picture to accompany the narrative you submit, please check the box provided. Each narrative is limited to 1000 words for purposes of the MIS data system. Wh ile you can enter words past this limit, they will not be displayed when data is pulled from MIS. If you have a picture to accompany anecdote #1, please check here (Narrative item #1) **F. Performance Measures** Device reu se activities are covered by the Acquisition Performance Measure. To report d ata for this measure, statewide AT programs will collect follow- up information from consumers to complete the tables below. Refer to the “General Instructions” for guidance on how to categorize the primary purpose for which AT devices/services are needed

. Performance measure for exchange, re assignment/refurbishment and repair and open ended device loan activities should be reported in the table below. The number of customers reported should equal the total number reported in (ii) of Section A

.

**Response Primary**  **Purpose for Which A T is Needed**  **Total Education**  **Employ ment**  **Community Living**  1. Could only afford the AT through the statewide AT program (n,d) 2. AT was only available through the statewide AT program (n,d) 3. AT was available throu gh other programs, but the**Reuse**

Page 24 system was too complex or wait time was too long (n,d) 4. Subtotal System generated System generated System generated 5. None of the above (d) 6. Subtotal System generated System generated System generated 7. No nrespondent (d) 8. Total System generated System generated System generated System generated 9. Performance on this measure System generated System generated System generated NOTES: Items marked (n) are included in numerator. Items marked (d) are included in denominator. Nonrespondents are included in the denominator for calculation of performance. (System will generate an error message if total reported in column at far right does not equal total of Sections A.ii ) **G. Customer Satisfaction**  Use data from customer surveys (which include an item about satisfaction) to complete the table below for all customers served by device reu se activities. **Customer Rating of Services Number of Customers**  **Percent** Highly satisfied System -generated Satisfied System -generated Satisfied somewhat System -generated Not at all satisfied System -generated Nonrespondent System -generated **Total surveyed** System -generated **Response rate** System -generated (System will generate an error message if total survey ed is not equal to the number of individuals who acquired a reused device reported in Section A (i)

. **H. Notes**  Describe any unique issues that may affect your data in this section

. If you have a device exchange program, please describe your data collecti on method, any challenges with collecting these data, and plans for overcoming those challenges. (Narrative item)Page 25 

### Device Loans **Outline** Overview of Activities Performed A. Short -Term Device Loans by Type of Purpose B. Number of Device Loans by Type of Borro we r C. Length of short - term device loans D. Types of devices loaned E. Anecdote F. Performance measures G. Customer satisfaction H. Notes Section 4f requirement: the number, type, and length of time of loans of assistive technology devices provided to individuals with di sabilities, employers, public agencies, or public accommodations through the device loan program...and an analysis of individuals with disabilities who have benefited from the device loan program Statewide AT programs provide short - term loans of AT devices to individuals or entities. The purpose of the loan may be to assist in decision making, to serve as a loaner while the consumer is waiting for device repair or funding, to provide an accommodation on a short - term basis for a time - limited event , for train ing , self- education or other p rofessional development activities

. L oans for the purpose of decision - making should be included in the access performance measure . Loans for all other purposes: providing a device during repair or while waiting for funding , providing an accommodation for a time - limited event , and training or personnel development should be included in the acquisition performance measure. In this section, report only on short - term loans in which devices are borrowed for a limited or prescrib ed amount of time for one of the four purposes described in Section A

. Based on national data, typical short - term loan periods range from between 30 and 45 calendar days. Device loans for significantly longer periods should be reviewed as possible open - ended loans , especially when the loan structure is done as an alternative to device ownership transferring to the consumer

. O pen - ended device loans, in which the device borrower can keep the device for as long as it is needed , should be reported under “De vice Reu se .” **Overview of A** **ctiv ities Performed**  Did your approved State Plan for this reporting period include conduct ing short - term device loans ? check yes or leave unchecked.**Device Loans**

Page 26 **A. Short**  **- Term Device Loans by**  **Ty pe of Purpose**  In this section, report the tota l number of short- term device loans made during the reporting period. A loan (counted as one) is defined as an occasion on which a device or devices were borrowed by an individual/entity who will use the device for one of the following purposes

– 1 ) T o ma ke a decision (one decision) based on data, judgments, and other relevant information gained from trial use of the device in a natural environment with technical assistance available , upon request, from someone who has technical expertise related to the de vice(s) borrowed

. 2 ) T o provide loaner equipment during device repair or while waiting for funding (no decision is involved)

. 3 ) T o provide an accommodation for a time - limited event such as a meeting or situation such as a hospital stay (no decision is i nvolved)

. Device loans that provide access to education , employment, or community living for as long as the individual has the device out on loan should be reported as an open - ende d loan

. 4) T o conduct training, self- education, or other p rofessional devel opment activit ies (no decision involved)

. The number of short - term device loans will equal the number of borrowers reported in B , as each loan will be classified by the type of individual or entity that borrows . The number of loans will NOT necessarily e qual the number of devices borrowed as reported in D as there may be multiple devices borrowed within a single loan. Use the following guidelines to determine the number of short - term device loans made: If the same individual or entity borrows devices on more than one occasion during the reporting period, count each occasion as a separate loan if a separate decision will be made If the same individual or entity borrows devices on more than one occasion during the reporting period and a single decision wil l be made, count that as one device loan. If you extend the period of a short- term device loan, count that as a separate loan only if (1) the extension is for a different purpose than the original loan and a separate decision will be made; or (2) the bor rower is an “intermediary” borrowing on behalf of others (e.g., a teacher), and the intermediary is requesting an extension to accommodate a second “end user” (i.e., an individual other than the one for whom the loan was initially made) and a second decisi on will be made.**Device Loans**

Page 27 Report the number of short - term device loans made by primary purpose of the loan. Count each loan in only one category, even if the loan included multiple devices. If at least one device included in the loan was obtained for the purpose of decision - making, report the loan in the first row

.

**Primary Purpose of Short**  **- Term Device Loan**  **Number of Loans**  Assist in decision making (device trial or evaluation) Access Performance Measure Serve as loaner during device repair or while waiting for funding Acquisition Performance Measure Provide an accommodation on a short - term basis for a time - limited event/situation Acquisition Performance Measure Conduct training, self- education or other p rofessional development activity Acquisition Performance Measure **Total** i. System generated **B. Number of Device Loans by**  **Ty pe of Borrower**  In this section, report the number of device loans by type of borrowers, by type of individual or entity. The total number of device borrowers should equal the total number of short - term device loans reported by primary purpose in Item A . You must be able to categorize borrowers to report them in this table as there is no option for “ unable to categorize ” or “other”

.

**Ty pe of Individual or Entity**  **Number of Device Borrowers** Individuals with disabilities Family members, guardians, and authorized representatives Representatives of Education Representatives of Employment Representatives of Health, allied health, and rehabilitation Representatives of Community Living Representatives of Technology **Total** System -generated**Device Loans**

Page 28 **C. Length of Short**  **- Term Device Loans**  Wh at is the length of a short- term device loan, as established by your statewide AT program’s policies not including extensions? Please report the length in ca lendar days. If your policy/procedures establish a range, use the midpoint. L ength of short - term device loan, in days: (Numeric field) **D. Ty**  **pes of Devices Loaned** Enter the number of devices that were loaned, by type of device. For guidance on how to categorize devices, refer to the “General Instructions.” The number of devices loaned may exceed the number of loans reported above in Item A , since a loan may include more than one device.

**Ty pe of**  **AT Dev**  **ice Number**  Vision Hearing Speech communication Learning, cognition, and developmental Mobility, seating and positioning Daily living Environmental adaptations Vehicle modification and transportation Computers and related Recreation, sports, and leisure **Total** System -generated **E. An**  **ecdote** Provide ONE anecdote about an individual who benefited from a device loan activity. For guidance on information to include in the anecdote, please see the “General Instructions.” If you have a picture to accompany the narrative you submit, please check the box provided. Each narrative is limited to 1000 words for purposes of the MIS data system. Wh ile you can enter words past this limit, they will not be displayed when data is pulled from MIS. If you have a picture to accompany anecdote #1, ple ase check here (Narrative item #1)**Device Loans**

Page 29 **F. Ac**  **cess Performance Measures**  Device loan activities for a decision - making purpose are covered by the Access Performance Measure. To collect data for this measure, statewide AT programs will collect data from all customers who obtained device loans for the purpose of decision making (i.e., the number reported in Item B. Row A). That data will be used to complete the table below. Refer to the “General Instructions” for guidance on how to categorize the primary purpose for which AT devices/services are needed.
**Response Primary**  **Purpose for Which A T is Needed**  **Total Education**  **Employ ment**  **Community Living**  1. Decided that an AT device/service will meet needs (n,d) 2. Decided that an AT device/se rvice will not meet needs (n,d) 3. Subtotal System generated System generated System generated 4. Have not made a decision (d) 5. Subtotal System generated System generated System generated 6. Nonrespondent (d, if > 35%) 7. Total S ystem generated System generated System generated System generated 8. Performance on this measure System generated System generated System generated NOTES: Items marked (n) are included in numerator. Items marked (d) are included in denominator. Nonrespondents in excess of 35% are included in the denominator for calculation of performance. (System will generate an error message if total reported in column on far right does not equal total reported in Item A , Row 1 .)

. **G. Ac**  **quisition Performance Measu**  **res** Device loan activities for the purpose of providing loaner equipment during device repair or while waiting for funding , for providing an accommodation for a time - limited event , and for professional development activities are covered by the Acquisition Performance Measure. To report data for this measure, statewide AT programs will collect follow- up information from consumers to complete the table below. Refer to the “General Instructions” for guidance on how to categorize the primary purpose for which AT devices/services are needed. The number of borrowers reported must equal the total number reported in rows 2 , 3 , and 4 of Section A.**Device Loans**

Page 30 **Response Primary**  **Purpose for Which A T is**  **Needed Total**  **Education Employ**  **ment Community**  **Living** 1. Could only afford to borrow the AT through the statewide AT program (n,d) 2. AT was only available through the statewide AT program (n,d) 3. AT was available to borrow from other programs, but the system was too complex or the wait time was too long (n,d) 4. Subtotal System generated System generated System generated 5. None of the above (d) 6. Subtotal System generated System generated System generated 7. Nonrespondent (d if > 35%) 8. Total System generated System generated System gener ated System generated 9. Performance on this measure System generated System generated System generated NOTES: Items marked (n) are included in numerator. Items marked (d) are included in denominator. Nonrespondents are included in the denominator for calculation of performance. (System will generate an error message if total reported in column at far right does not equal total of Sections A rows 2 + 3 + 4

. ) **H. Customer Satisfaction**  Use data from customer surveys (which include an item about sat isfaction) to complete the table below for all customers served by device loans (total in A.i

. ) **Customer Rating of Services Number of Customers**  **Percent** Highly satisfied System -generated Satisfied System -generated Satisfied somewhat System -generated Not at all satisfied System -generated Nonrespondent System -generated **Total** System -generated **Response rate** System -generated**Device Loans**

Page 31 **I .**  **Notes** Describe any unique issues that may affect your data in this section (e.g., types of devices that are not loaned be cause those loans are available from another source, or types of devices that are not loaned because your inventory does not include those devices, difficulty obtaining data from intermediaries, etc.) (Narrative item)Page 32 

### Device Demonstrations **Outline** Ove rview of Activities Performed A. Number of Device Demonstrations by Device Type B. Types of participants C. Number of referrals D. Anecdote E. Performance measures F. Customer satisfaction G. Notes Section 4f requirement: the number and type of device demonstrations and r eferrals provided and an analysis of individuals with disabilities who have benefited from the demonstrations and referrals Device demonstrations compare the features and benefits of a particular AT device or category of devices for an individual or smal l group of individuals. The purpose of a device demonstration is to enable an individual to make an informed choice. Wh enever possible, the participant should be shown a variety of devices. Device demonstrations should not be confused with training acti vities at which devices are demonstrated. Training activities are instructional events designed to increase knowledge, skills, and competencies, generally for larger audiences . Training can also be targeted/focused instruction for an individual or small group (such as in - depth training for an individual consumer on a specific AT device ). This targeted training is for skill development whereas device demonstration s are for decision - making purposes

. Device demonstrations also should not be confused with p ublic awareness activities at which devices are demonstrated. The key difference is that device demonstrations are intended to enable an individual to make an informed choice rather than merely making him or her aware of a variety of AT. In a device demo nstration for an individual, guided experience with the device(s) is provided to the participant with the assistance of someone who has technical expertise related to the device(s). This expert may be in the same location as the participant or may assist the participant through Internet or distance learning mechanism that provides real - time, effective communication to deliver the necessary device exploration. (See the instructions for further clarification and examples.) As noted in the instructions for this section, a device demonstration referral is p rovision of information about a specific source where the customer may obtain additional information or services related to AT. A referral must provide a consumer with information on how to contact that so urce directly. Referrals may be made to funding sources, service providers, vendors, or repair services. Do not include referrals to other components of your statewide AT program. Report only on referrals that result from**Device Demonstrations**

Page 33 demonstration activities, not referrals made through an information and assistance activities. **Overview of A** **ctiv ities Performed**  Did your approved State Plan for this reporting period include conduct device demonstrations? Check yes or leave unchecked. **A. Number of Device Demonstrations**  **by Dev**  **ice Ty pe**  In this section, report the number of device demonstrations by type of device/service demonstrated during this reporting period. For guidance on how to categorize devices and services, refer to the “General Instructions.” A device demons tration (counted as one) is defined as an occasion in which one or more devices within a category are demonstrated to an individual or small group who will make a decision (one decision) based on data, judgments, comparisons and other relevant information gained from the interaction with the equipment and demonstrator. The number of device demonstrations will NOT necessarily equal the number of demonstration participants reported in B as there may be multiple participants in a demonstration even though onl y one decision will be made.

**Ty pe of**  **AT Dev**  **ice/Service Number of Demonstrations**  **of this Type of A T**  **Device/Service** Vision Hearing Speech communication Learning, cognition, and developmental Mobility, seating and positioning Daily living Environmental adaptations Vehicle modification and transportation Computers and related Recreation, sports, and leisure **Total** System -generated **B. Types of Participants**  In the table below, enter the number of individuals who participated in d evice demonstrations, by type of participant. Include all individuals participating in demonstrations, not just those who are making a decision (or for whom a decision is being made). For guidance on how to categorize participants, refer to the “General Instructions.” You must be able to categorize participants to report them in this table as there is no option for “unable to categorize” or “other”.**Device Demonstrations**

Page 34 **Ty pe of Participant**  **Number of Participants in Device Demonstrations**  Individuals with disabilities Famil y members, guardians, and authorized representatives Representatives of Education Representatives of Employment Representatives of Health, allied health, and rehabilitation Representatives of Community Living Representatives of Technology **T otal**  System -generated **C. Number of Referrals**  In this section, report the number of referrals made to each type of entity. Since participants in a demonstration may receive more than one referral, or may not be referred at all, the number of referrals m ay be greater or less than the number of participants and number of demonstrations. Do not include referrals to other components of your statewide AT program.

**Ty pe of Entity**  **Number of Referrals** Funding source (non -AT program) Service provider Vendor Repair service Others **D. An**  **ecdote** Provide ONE anecdote about an individual who benefited from a device demonstration activity. For guidance on information to include in the anecdote, see “General Instructions.” If you have a picture to accompan y the narrative you submit, please check the box provided. Each narrative is limited to 1000 words for purposes of the MIS data system. Wh ile you can enter words past this limit, they will not be displayed when data is pulled from MIS. If you have a pict ure to accompany anecdote #1, please check here (Narrative item #1)**Device Demonstrations**

Page 35 **E. Performance Measures**  Device demonstrations are covered by the Performance Measure 1 (access). To collect data for this measure, statewide AT programs will collect data from the identified decision - maker who participated in demonstrations (one per demonstration as reported in Item A)

. That data will be used to complete the table below. Refer to the “General Instructions” for guidance on how to categorize the prim ary purpose for which AT devices/services are needed.

**Response Primary**  **Purpose for Which A T is Needed**  **Education Employ**  **ment Community**  **Living Total**  1. Decided that an AT device/service will meet needs (n,d) 2. Decided that an AT device/service wil l not meet needs (n,d) 3. Subtotal System generated System generated System generated 4. Have not made a decision (d) 5. Subtotal System generated System generated System generated 6. Nonrespondent (d) 7. Total System generated System generated System generated System generated 8. Performance on this measure System generated System generated System generated NOTES: Items marked (n) are included in numerator. Items marked (d) are included in denominator. Non - respondents are in cluded in the denominator for calculation of performance. (System will generate an error message if total reported in column on far right does not equal total reported in Section A. ) **F. Customer Satisfaction**  Use data from customer surveys (which includ e an item about satisfaction) to complete the table below for all customers served by device demonstration. **Customer Rating of Services Number of**  **Customers Percent**  Highly satisfied System -generated Satisfied System -generated Satisfied somewhat System -generated Not satisfied System -generated**Device Demonstrations**

Page 36 Nonrespondent System -generated **Total** System -generated **Response rate** System -generated (System will generate an error message if total does not equal total reported in Section B .) **G . Notes**  Describe any unique issues that may affect your data in this section (e.g., types of participants that may appear to be underrepresented because they receive demonstration services from another organization, types of devices/services that are not demonstrated because t hose demonstrations are available from another source, issues related to use of distance education mechanisms to deliver demonstrations, or issues related to dissatisfaction (e.g.; consumer may be dissatisfied because they assumed the AT Program could purchase the device for them) (Narrative item)Page 37

Overall Acquisition Performance Measure (auto - populated) The acquisition performance measure is the sum of State Financing , Reuse and Short term Device Loan (purposes of providing device during repair, while waiting for funding and short - term accommodation) performance measure data.

Overall Access Performance Measure (auto - populated) The access performance measure is t he sum of Short - term Device Loan (decision making purposes) and Device Demonstration performance measure data.

**Response Primary**  **Purpose for Which A t is**  **Needed Total**  **Education Employ**  **ment Community**  **Living** 1. Decided that an AT System - System - System - System **Response Primary**  **Purpose for Which A T is Needed**  **Total Education**  **Employ ment**  **Community Living**  1. Could only afford the AT through the statewide AT program System generated Sy

stem generated System generated System generated 2. AT was only available through the statewide AT program System generated System generated System generated System generated 3. AT was available through other programs, but the system was too complex o r the wait time was too long System generated System generated System generated System generated

4. Subtotal System generated System generated System generated System generated 5. None of the above System generated System generated System generated Sy

stem generated 6. Subtotal System generated System generated System generated System generated 7. Nonrespondent System generated System generated System generated System generated 8. Total System generated System generated System generated System ge nerated 9. Performance on this measure System generated System generated System generated System generated 10. RSA Performance Target 11. Met or Not Met**Training**

Page 38 device/service will meet needs generated generated generated generated 2. Decided that an AT device/service will not meet needs System generated System generated System generated System generated 3. Subtotal System generated System generated Syste m generated System generated 4. Have not made a decision System generated System generated System generated System generated 5. Subtotal System generated System generated System generated System generated 6. Nonrespondent System generated System gen erated System generated System generated 7. Total System generated System generated System generated System generated 8. Performance on this measure System generated System generated System generated System generated 9. RSA Performance Target 10. Met/Not Met**Training**

Page 39 

### Training **Outline** Overview of Activities Performed A. Training participants: Number and types of participants; geographical distribution B. Training topics C. Description of training activities D. Notes Section 4f requirements: Training 1. “t he number and general characteristics of individuals who participated in training...(such as individuals with disabilities, parents, educators, employers, providers of employment services, health care workers, counselors, other service providers, or vendors) ” 2. ”the topics of such training” 3. “to the extent practicable, the geographic distribution of individuals who participated in the training.” Transition: No explicit reporting requirement in Section 4f, but Section 4e includes requirement that statewide AT programs provide training and technical assistance to assist students with disabilities who receive transition services under IDEA and adults with disabilities maintaining or transitioning to community living. Section e also requires that at least 5% o f the money spent on State Leadership activities be used for transition activities. The AT Act of 1998, as amended provides a combined description of training and technical assistance (see Section - Specific Definitions). Following is guidance on what act ivities to report in this section and how to distinguish training activities from public awareness or technical assistance activities. Report each activity only once, in the appropriate section. This section of the reporting form also collects informatio n on training activities that are related to transition. Information on technical assistance activities related to transition should be reported in that section of the form. Reminder- each Statewide AT Program must report on at least one transition activi ty related to school transition (e.g., secondary school to post - school) AND one transition activity related to community living transition (e.g. congregate living to community living). The activity reported may be either a training event or a technical as sistance initiative. Training activities are instructional events, usually planned in advance for a specific purpose or audiences, which are designed to increase participants’ knowledge, skills, and competencies regarding AT. Such events can be delivered to large or small groups, in - person, or via telecommunications or other distance education mechanisms. In general, participants in training can be individually identified and could complete an evaluation of the training. Examples of training include clas ses, workshops, and**Training**

Page 40 presentations that have a goal of increasing skills, knowledge, and competency, as opposed to training intended only to increase general awareness of AT. **Distinguishing Training A ctiv**  **ities from Public A war** **eness A ctivities**  Training act ivities have more depth and breadth than public awareness activities and are focused on skill building and competency development. If the purpose of a training session is to create awareness, the training session should be counted under public awareness, n ot under training. In general, participants in training can be individually identified, while in awareness activities, it may not be possible to identify each individually. Wo rking with individual consumers on how to use a particular AT device or trouble shooting problems with devices should be reported under Public Awareness as “Information and Assistance.” **Distinguishing Training from Technical A ssistance**  Training is designed to teach, present, or guide individuals in order to impart knowledge, skills, and competencies. Technical assistance is focused on providing extensive assistance to state or local agencies or other entities (rather than individuals) and generally involves problem solving to achieve a mutually agreed - upon goal. Technical assistance may involve multiple contacts and interactions over an extended period of time. In some cases, training may be a component of technical assistance. Training that is provided as part of technical assistance can be reported here, but only if the training was one of several technical assistance activities. If training was the only technical assistance activity, it can be reported as either training or technical assistance, but not both. **Overview of A** **ctiv ities Performed**  Training activities are required an d must be reported as described below. **A. Training Participants: Number and Ty**  **pes of Participants; Geographical Distribution**  1. Enter the number of training participants by type. The participant may selfdetermine the appropriate descriptor for themselves or such information may be derived from other training event records. Use “ unable to categorize ” when no data can be obtained on type of participant

.

**Ty pe of Participant**  **Number** Individuals with disabilities Family members, guardians, and authorized**Training**

Page 41 repre sentatives Representative of Education Representative of Employment. Representative of Health, allied health, and rehabilitation Representative of Community Living Representative of Technology Unable to C ategorize **Total** 2. Enter the n umber of individuals who participated in training, by the Rural Urban Continuum Code (RUCC) of the participant’s county. For a consumer, you determine the RUCC by the county in which he or she resides. For a representative, you determine the RUCC by the county in which they generally provide services. Training participants for whom you cannot determine a county are counted in “Unknown.” For a dditional guidance on the RUCC , refer to the “General Instructions.” **Metro (RUCC 1 -**  **3) Non Metro (RUCC 4**  **- 9)**  **Unknow n**  **TOTA L**  The Total in A(2) a bove must equal the Total of A(1)**Training**

Page 42 **B. Training Topics**  Enter the number of participants by the primary purpose of the training. Training topics are organized into categories: 1. AT products and services, which includes subcatego ries of AT types. 2. AT funding, policy and practice, which includes subcategories of common topics in this category and space other related AT topics. 3. Information Technology/Telecommunications which includes subcategories of related uses of information tec hnology and telecommunications products. **For participants in this training topic, y** **ou w ill need to collect a performance**  **measure, see Data Collection Instrument IT/Telecommunication Training Performance Measure.**  4. Combination of AT products and services, AT funding, policy and practice and/or IT/Telecommunications. (Use this category only when absolutely necessary.) 5. Transition, including transition from school to work or postsecondary education and transition to community living. (Use this category for A LL transition activities even if they could be reported as AT Products/Services, AT Funding/Policy, etc.) **Primary Topic of Training**  **Number of Training**  **Participants** 1. AT Products/Services Training focused on AT: such as instruction to increase skills and competency in using AT, and integrating AT into different settings 2.AT Funding/Policy/ Practice Training focused on funding sources and related laws, policies, and procedures required to implement and deliver access to AT devices/services and related. 3.Information Technology/Telecommunication Access Training focused on accessible information technology and telecommunications including web access, software accessibility, procurement of accessible IT and telecommunications, etc. A performance m easure must be collected for these training participants 4 Combination of any/all of the above -- AT Products/Services, AT Funding/ Policy/Practice and/or IT/Telecommunications Access**Training**

Page 43 5.Transition Training focused on education transition (school to work or post secondary education and early intervention (birth to 3) to school aged (3 - 21) and community transition ( maintaining or transitioning to community living). ( Note: A n umber must be reported here unless t ransition technical a ssistance activity /activit ies are reported .) **Total** System generated The Total Number of Training Participants must equal the Total in A(1) and A(2)

. **C. Description of Training A** **ctiv ities**  In Item 1 below, describe an innovative or high - impact training activity that is not related to transition. In Item 2 below, describe a training activity that is related to transition. 1. Briefly describe one innovative or high - impact training activity conducted during this reporting period. Note who conducted the training (e.g., type of expertise of staff) and characteristics of the audience (including number that attended). In one sentence, describe the topic, content, and/or approach of the training. In one sentence, summarize the positive result or intended impact of the training. Do not inc lude overall descriptions of conferences held, unless the conference had a unique purpose/outcome. Narrative item - Each narrative is limited to 1000 words for purposes of the MIS data system. W hile you can enter words past this limit, they will not be di splayed when data is pulled from MIS. 2. Briefly describe a training activity related to transition conducted during this reporting period. Note who conducted the training (e.g., type of expertise of staff) and characteristics of the audience (including nu mber that attended). In one sentence, describe the topic, content, and/or approach of the training. In one sentence, summarize the positive result or intended impact of the training. Do not include overall descriptions of conferences held, unless the co nference had a unique purpose and outcome. **This section must be completed unless yo**  **u are reporting t**  **ransition t** **echnical a**  **ssistance activities**

. **If this section is completed, an associated number of training participants must be**  **reported in Section B Row 5** 

. Narrative item - Each narrative is limited to 1000 words for purposes of the MIS data system. W hile you can enter words past this limit, they will not be displayed when data is pulled from MIS.**Training**

Page 44 **D. IT/Telecommunications Training Performance Measure O**  **utcome/result from IT/Telecommunication Training Received Number**  IT and telecommunications p rocurement or development policies, procedures, or practices will be improved or better implemented to ensure accessibility. (n ,d ) Training or technical assistan ce will be developed or implemented to ensure accessibility of IT and telecommunications . (n ,d ) No know n outcome at this time . (d) Nonrespondent (d) **TOTA L**  (must equal number reported in Section B.3) System generated **Performance Measure Percenta ge**  System generated **RSA Target Percentage**  **Met/Not Met E.**  **Notes** Describe any unique issues that may affect the data in this section, (e.g., reasons why particular topics or audiences were emphasized or were not included during this reporting period)

. (Narrative item)Page 45 

### Technical A

**ssistance Outline**  Overview of Activities Performed A. Frequency and nature of technical assistance B. Description of technical assistance activities C. Notes Section 4f requirements: Technical Assistance “T he frequency of prov

ision and nature of technical assistance provided to State and local agencies and other entities.” Transition: No explicit reporting requirement in Section 4f, but Section 4e includes requirement that AT programs provide training and technical assistance to assist students with disabilities who receive transition services under IDEA and adults with disabilities maintaining or transitioning to community living. Section e also requires that at least 5% of the money spent on State Leadership activities be use d for transition activities. The AT Act of 1998, as amended provides a combined description of training and technical assistance (see “General Definitions”). Additional descriptions of technical assistance activities are provided below, along with guid ance for distinguishing technical assistance activities from public awareness activities and training activities. Technical Assistance (TA) is defined as direct problem - solving service provided by Statewide AT Program staff to assist programs and agencies in improving their services, management, policies, and/or outcomes. TA may be provided in person, by electronic media such as telephone, video, or e - mail, and by other means. The following are examples of technical assistance: needs assessment, program planning or development, curriculum or materials development, administrative or management consultation, program evaluation and site reviews of external organizations, and policy development. Mandatory transition activities that are technical assistance are reported in this section; mandatory transition activities that are training are reported in the training section. Reminder- each Statewide AT Program must report on at least one transition activity related to school transition (e.g., secondary school to post - school) AND one transition activity related to community living (e.g. maintaining or transitioning to community living). The activity reported may be either a training event or a technical assistance initiative.**Technical A ssistance** 

Page 46 **Distinguishing Technical Assistance from**  **Information & Assistance** Technical assistance is provided to agencies or other organizations, not to individuals. Intensive support provided to an individual, for example assisting an individual troubleshoot problems with an AT device or address a f unding issue, is reported under information and assistance. Technical assistance typically include s multiple contacts/interactions over an extended period of time with an agency or organization

. Less intensive support services, including single - contact requests for information or limited assistance from agencies or organizations should also be reported under information and assistance

. **Distinguishing Technical Assistance from Training** Training is designed to teach, present, or guide individuals in order to impart knowledge, skills, and competencies to individuals, while technical assistance may be designed to help entities (not individuals) improve their policies, practices, and procedures and generally involve problem solving. In some cases, training m ay be a component of technical assistance. Training that is provided as part of technical assistance can be reported in the training section, but only if the training was one of several technical assistance activities. If training was the only technical assistance activity, it can be reported as either training or technical assistance, but not both. **Over view** **of A ctiv**  **ities Performed** Technical Assistance activities are required and all activities should be reported in the aggregate in Section A. One Techn ical Assistance activity must be described in Section B and a transition Technical Assistance activity must be reported unless a transition training activity was reported. **A. Frequency** 

**and Nature of Technical A ssistance**  Complete this section summarizing all major technical assistance activit ies that you conducted. Indicate the percentage of total technical assistance provided by the type of program or agency receiving the technical assistance. Use the person hours invested in each technical assistance a ctivity to report the percentage by type of program or agency . For example, if you conducted two major TA activities this reporting period with 90 total person hours for an activity related to education and 50 person hours for an activity related to e mplo yment, you would report 64% in education and 36% in Employment.**Technical A ssistance** 

Page 47 **Program or agency**

**receiv ing technical assistance**  **Percentage of all TA** Education Employment Health, Allied Health, Rehabilitation Community Living Technology (Information Technology , Telecommunications, Assistive Technology) Total Must equal 100% **B. Description of Technical A ssistance A** **ctivities** In Item 1 below, describe an innovative or high - impact technical assistance activity that is not related to transition. For this item , choose a technical assistance activity that had an outcome. In Item 2 below, describe a technical assistance activity that is related to transition. The transition technical assistance activity is not required to have an outcome. 1. Describe in detail one innovative or high - impact technical assistance activity conducted during this reporting period. Note who provided the technical assistance (e.g., type of expertise of staff) and characteristics of the recipient a gency. In two sentences: (1) describe the topic, content, and/or approach of the technical assistance; and (2) summarize the positive result or impact of the technical assistance. Narrative item - Each narrative is limited to 1000 words for purposes of the MIS data system. Wh ile you can ente r words past this limit, they will not be displayed when data is pulled from MIS. 2. Briefly describe one technical assistance activity related to transition conducted during this reporting period. Note who provided the technical assistance (e.g., type of expertise of staff) and characteristics of the recipient agency. In two sentences: (1) describe the topic, content, and/or approach of the technical assistance; and (2) summarize the positive result or impact of the technical assistance. **NOTE: This**  **section must be completed unless a transition training activity is reported.** Narrative item - Each narrative is limited to 1000 words for purposes of the MIS data system. Wh ile you can enter words past this limit, they will not be displayed when data is pulled from MIS.**Technical A ssistance** 

Page 48 **C. Notes** Describe any unique issues with data in this section (e.g., reasons why particular topics or audiences were emphasized or were not included during this reporting period). (Narrative item)Page 49



### Public A **wa reness and Information an**  **d A ssistance**  **Outline** Overview of Activities Performed A. Public awareness activities B. Information and Assistance C. Notes Section 4f requirement: “the number of individuals assisted through the public awareness activities and statewide information and referra l system”

. Public awareness activities are designed to reach large numbers of people, including activities such as public service announcements, radio talk’s shows and news reports, newspaper stories and columns, newsletters, brochures, and public forum s. Actual numbers of information recipients are often difficult to know for certain, but should be reported when known, and in other cases estimated as accurately as possible. Public awareness activities should be reported, as accurately as possible, in Pa rt A of this section. Information and assistance includes provision of information and supports to individuals and provision of referrals to other entities. All of these activities may be provided in person, over the telephone, via email, or other effect ive communication mechanism s. **Distinguishing Information and Assistance from Device Demonstration Referral** In this section, report only on referrals resulting from information dissemination activities, such as calls to a 1 - 800 number or e - mails. Referra ls resulting from device demonstrations should be reported under device demonstrations. **Distinguishing Public Awareness from Training** The intended outcome of an activity should determine whether it is reported under public awareness or training. Include presentations made for the purpose of general awareness under public awareness. Do not include training sessions with the intended outcome of participants applying new knowledge or skills in addressing AT device/service issues (which should be reported und er training). **Overview of A** **ctiv ities Performed**  Public awareness and information and assistance activities are required and must be reported. **A. Public A** 

**wareness A ctiv**  **ities** In this section report on public awareness activities intended to reach a wide audie nce. In the table below enter the known or estimated number of individuals**Public A wa**  **reness and Information and A ssistance** 

Page 50 reached during the reporting period by each type of public awareness activity. Activities must be reported in one of the categories provided (there is no “other” category). The ca tegories provided should enable reported of all major public awareness activities. Presentations reported in this section are for the purpose of general awareness. Training sessions with the intended outcome of participants applying new knowledge or skil ls in addressing AT device/service issues should be reported as a training activity. (NOTE: Purchasing promotional items is not allowable under OMB Circular direction and as such should not be reported in this section.) **Public A wareness A** **ctiv ity**  **Estimat ed Number**  **of Individuals Reached** Newsletters Other print materials Listservs/blogs/social media Internet information Other electronic media PSA - radio/TV/other media Presentations/expos/conferences **Total B.**  **Information and A ssistance**  Information and assistance (I&A) activities are those in which the AT program responds to requests for information and/or puts individuals in contact with other agencies, organizations, or companies that can provide them with needed information on AT products, devices, services, or funding sources or provid es intensive assistance to individuals about AT products, devices, services, or funding sources. This information may be provided in person, over the telephone, via email, or by some other communication mechan ism

. In the table below report the number of individuals to whom you provided information and assistance services by type of individual or entity (see instructions for classification system explanation) and by the content of the information and assistance provided. To the extent practicable each unique request for information and assistance should be counted only once. For the content of the I&A provided, d ifferentiate between

–

 Information and assistance about specific AT products, devices, or service s, or selecting an AT product, device, or service; and  Information and assistance that addresses obtaining funding for or otherwise acquiring AT devices and services or providing AT policy/practice information**Public A wa**  **reness and Information and A ssistance** 

Page 51 **Ty pes of Recipients of**  **Information and A**

**ssis tance**  **AT Dev**  **ice/**

**Service AT**  **Funding/**

**Policy /Practice**  **Total** Individuals with disabilities System generated Family members, guardians, and authorized representatives System generated Representative of Education System generated Representative of E mployment System generated Representative of Health, Allied Health, and Rehabilitation System generated Representative of Community Living System generated Representative of Technology System generated Unable to Categorize System generated **Total** System generated System generated System generated **C. Notes**  Describe any unique issues with your data in this section. (Narrative item)**Data Collection Instrument**

Page 52 

### State Improvement Outcomes **Outline** Overview of Activities Performed A. State improvement outcomes B. State improvement outcome (if second one reported) It is understood and expected that AT Programs will coordinate and collaborate with other public and private entities in terms of receiving referrals, sharing information, serving on advisory board, etc. and will p rovide technical assistance to a variety of agencies and entities throughout the reporting period. Outcomes of state improvements initiatives must result in policy, practice or procedure improvements beyond those associated with or already reported in pre vious state - level and state leadership coordination and collaboration sections. Section 4f requirements: “ the outcomes of any improvement initiatives carried out by the State as a result of activities funded under this section, including a description of any written policies, practices, and procedures that the State has developed and implemented regarding access to, provision of, and funding for, assistive technology devices, and assistive technology services, in the contexts of education, health care, emp loyment, community living, and information technology and telecommunications, including e - government.” **Overview of A** **ctiv ities Performed**  State improvement outcomes are not required. You may report up to two MAJOR state improvement outcomes for this repo rting period. How many will you be reporting? (For example, you may have worked with your state Information Technology Office to implement an Executive Order related to web accessibility or may have worked with your Medicaid office to streamline procedures for obtaining wheeled mobility devices.)

-- enter zero, 1 or 2 **A. State Improvement Outcomes**  Complete this section for the first MAJOR state improvement outcome to be reported

. 1. In one or two sentences, describe the outcome. Be as specific as possible about exactly what changed during this reporting period as a result of the AT program’s initiative. (Narrative field) 2. In one or two sentences, describe the written policies, practices, and procedures that have been developed and implemented as a result o f the AT program’s initiative. Include information about how to obtain the full documents, such as a We b site address or e - mail address of a contact person, but do not include the full documents here. (If there are no written policies, practices, and proce dures, explain why.) (Narrative field)**Ad ditional and Leveraged Funds** 

Page 53 3. W hat was the primary area of impact for this state improvement outcome ? Drop - down box: Education

– Employment -- Health, Allied Health, Rehabilitation

-- Community Living -- Technology (Information Technology, Telecommunications, and Assistive Technology). **B State Improvement Outcome**  If you have a second MAJOR outcome to report, this section will need to be completed with items 1 through 3 above

.



### Ad **ditional and Leveraged Funds Outline**  Overview of Activities Per formed A. Leveraged Funding for State Plan Activities (Previously Reported) B. Leveraged Funding for Activities Not in State Plan (not previously reported) C. Notes Section 4f requirement: “(x) the source of leveraged funding or other contributed resources, including resources provided through subcontracts or other collaborative resource -sharing agreements, from and with public and private entities to carry out State activities described in subsection (e)(3)(B)(iii), the number of individuals served with the con tributed resources for which information is not reported under clauses (i) through (ix) or clause (xi) or (xii), and other outcomes accomplished as a result of such activities carried out with the contributed resources” **Overview of A** **ctiv ities Performed**  Did you have Additional and Leveraged Funding to report? (Check yes or leave unchecked). In this section, provide information on funding that has been leveraged to support statewide AT Program activities. Report only actual dollars leveraged; do NOT repo rt in kind contributions. The additional and leveraged funding reported in this section is NOT necessarily considered program income under federal guidelines. **A. Leveraged Funding for State Plan A** **ctiv ities (Previously**  **Reported )**  Statewide AT Programs often e stablish partnerships and leverage funds to support state implementation of required AT Act activities as described in your State Plan. These funds should be reported by entering the sources and amounts of non -AT Act funds that you received during this re porting period to support your State Plan activities. Report each source and amount in the reporting period that it was received, even if not all of the funds were expended in that reporting period. Do not report AFP endowments or matching funds. Identi fy which state level or leadership activity the funds were allocated to support. If funds were received to support more than one activity, report an**Ad ditional and Leveraged Funds** 

Page 54 amount for each activity according to funding allocations. The number of individuals served by those fund s or other outcomes should have already been reported in the appropriate previous sections. **Fund Source (select one)**  **Am ount**  **Use of Funds (select one)** Ο Federal Ο Public/State Agency Ο State Appropriations Ο Private Ο State Financing Ο Training Ο Reu se Ο Technical Assistance Ο Demonstration Ο Public Awareness, I&A Ο Device Loan option to repeat row data **B. Leveraged Funding for A ctiv**  **ities Not in State Plan ( data**  **not previously reported**  **in other activity sections )**  Statewide AT Programs may also leverage funds to support activities that are authorized by the AT Act but not included in a State Plan. For example, a state may administer external funding for an activity that could be reported as Other State Financing, b ut they choose not to include that data in the State Financing section. If an activity is approved as part of your state plan and has associated leveraged funding, it should NOT be reported here but should be reported in the previous section A. This sect ion is limited to only non - State Plan approved activities with leveraged funding that do not have information on individuals served or other outcome data reported in previous sections. Funds used to support these activities should be reported by entering the sources and amounts of non -AT Act funds that you received during this reporting period. Report each source and amount in the reporting period that it was received, even if not all of the funds were expended in that reporting period. Do not report AFP endowments or matching funds. Identify which activities those funds were allocated to support. Report the number of individuals served by each funding source identified ; or describe other outcomes if the “ individuals served ” is not an appropriate outcom e measure. **Fund Source Am**  **ount Use of Funds**  **– select**  **one Individuals Served**  **or Other Outcome**  Ο Federal Ο Public/State Agency Ο State Appropriations Ο Private Ο State Financing Ο Reu se Ο Demonstration Ο Device Loan Ο Training Ο Technical Assistance Ο Public Awareness, I&A (enter the number individuals served or describe th e outcome)**Ad ditional and Leveraged Funds** 

Page 55 option to repeat row data **C. Notes** Describe any unique issues with your data in this section (e.g., the reason why you were unable to report the number of individuals served with additional or leveraged funds). (Narrative item)**Data Collection Instrument**

Page 56 

### Data **Collection Instrument Ac**  **cess Performance Measure TO BE COMPLETED BY PROGRAM STAFF**  ID (optional) ____________ S e r v i c e s p ro v i d e d : **Device demonstration OR**  **Device loan (decision**  **- making purpose)**  D a t e s e r v i c e d e l i ve ry wa s c o m p l e te d :

_ _ _ _ _ _ _ _ _ _ D a t e t h i s fo rm wa s re c e i ve d :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Please a nswer the following questions about the services you received from the (insert name of statewide AT program or its subcontractor). Weneed this inform ation to provide high quality services and to m eet the requirem ents for receiving federal funding

. 1. The p rim ary purpose for w hich I need (or the person I represent needs) an AT device or service is related to: **(Please mark only one answer.) Education** 

— participating in any type of educational program **Community**

**liv ing** 

—carry ing out daily activities, participating in community activities, using comm unity services, or living independently **Employment**

—finding or keeping a job; getting a better job; or participating in an em ploym ent training program, vocational rehabilitation program , or other program related to em ploym ent 2. Wh at kind of decision about AT devices or services were you (or som eone you represent) able to m ake after your device dem onstration or device loan? **(Please mark only one answer.)**

_____ Deci ded that an AT device or service will m eet m y needs (or the needs of som eone I represent).

_____ Decided that an AT device or service will not me et m y needs (or the needs of som eone I represent).

_____ Have not m ade a decision. Paperwork Burden Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information is 1820 - 0572 . The time requi red to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to U.S. Department of Education, W ashington DC, 20202. If you have any comments or concerns regarding the status of your individual submission o f this form, write directly to Mr. Robert Groenendaal , Rehabilitation Services Administration, U.S. Department of Education, Potomac Center Plaza, Room 5025, 400 Maryland Ave. S W, W ashington, DC, 20202 - 2800.**Data Collection Instrument**

Page 57 

### Data Collection Instrument **Ac quisition Performa**  **nce Measure (SFA**  **and Reuse) TO BE COMPLETED BY PROGRAM STAFF**  I D ( o p t i o n a l )

____________ S e r v i c e s p ro v i d e d : **“State financing” services —**  **including financial loan, assistance in accessing funds for AT devices/services, assistance in obtaining AT devices and**  **services at reduced cost or free, o r other related services**  **Device reuse**

**— received an AT device through a device exchange,**  **reassignment/refurbish or repair or open -**  **ended loan program** D a t e s e r v i c e d e l i ve ry wa s c o m p l e t e d :

_ _ _ _ _ _ _ _ _ _ D a t e t h i s fo r m wa s re c e i v e d :

_ ___________________ Please answer the following questions about the services you received from (insert name of statewide AT program or its subcontractor) . W e need this inform ation to provide high quality services and to meet the requirem ents for receivin g federal funding. 1. The prim ary purpose for w hich I need (or the person I represent needs) an AT device or service is related to: **(Please mark only one answer.) Education** 

— participating in any type of educational program **Community**

**liv ing** 

—carrying out daily activities, participating in community activities, using comm unity services, or living independently **Employment**

—finding or keeping a job; getting a better job; participating in an em ploym ent trai ning program, vocational rehabilitation program , or other program related to em ploym ent 2. Wh y did you chose to obtain an AT device/service from our program ? **(Please mark only one answer.)**

_____ I could only afford the AT through this program . (I could n ot afford it through other program s.)

_____ The AT was only available to m e through this program. (I am not eligible or don't qualify for other program s, the AT is not covered by other funding sources or the specific device I needed is not provided by ot her program s.)

_____ The AT was available to m e through other program s, but the system was too com plex or the wait time was too long.

_____ None of the above Paperwork Burden Statement According to the Paperwork Reduction Act of 1995, no persons are requi red to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information is 1820 - 0572 . The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestio ns for improving this form, please write to U.S. Department of Education, W ashington DC, 20202. If you have any comments or concerns regarding the status of your individual submission of this form, write directly to Mr. Robert Groenendaal , Rehabilitation Services Administration, U.S. Department of Education, Potomac Center Plaza, Room 5025, 400 Maryland Ave. S W, W ashington, DC, 20202 - 2800.**Data Collection Instrument**

Page 58 

### Data Collection Instrument **Ac quisition Performance Measure (Device Loan)**  **TO BE COMPLETED BY PROGRAM STAFF** I D ( o p t i o n a l )

____________ Short - term device loan purposes : **Provi di**  **ng loaner equipment during device repair or while waiting for funding Providing an accommodation for a time** **- limited**  **event Conducting training, self**  **- education or other professional development**  **activity** D a t e s e r v i c e d e l i ve ry wa s c o m p l e t e d :

_ _ _ _ _ _ _ _ _ _ D a t e t h i s fo r m wa s re c e i v e d :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Please answer the following questions ab out the services you received from (insert name of statewide AT program or its subcontractor) . W e need this inform ation to provide high quality services and to meet the requirem ents for receiving federal funding. 1. The prim ary purpose for w hich I need ( or the person I represent needs) an AT device or service is related to: **(Please mark only one answer.) Education** 

— participating in any type of educational program **Community**

**liv ing** 

—carrying out daily activities, particip ating in community activities, using comm unity services, or living independently **Employment**

—finding or keeping a job; getting a better job; participating in an em ploym ent training program, vocational rehabilitation program , or other prog ram related to em ploym ent 2. Wh y did you chose to borrow an AT device/service from our program ? **(Please mark only one answer.)**

_____ I could only afford to borrow the AT through this program. (I could not afford to rent or borrow it through other program s.)

_____ The AT was only available to m e through this program. (I am not eligible or there is no other rental or device loan program available; or the specific device I needed is not loaned by other program s.)

_____ The AT was available to borrow from other program s, but the system was too com plex or the wait time was too long. (I couldn’t borrow the device in a tim ely manner.)

_____ None of the above Paperwork Burden Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information is 1820 - 0572 . The time required to complete this information collection is estimated to average 5 minute s per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to U.S. Department of Education, W ashington DC, 20202. If you have any comments or concerns regarding the status of your individual submission of this form, write directly to Mr. Robert Groenendaal , Rehabilitation Servic es Administration, U.S. Department of Education, Potomac Center Plaza, Room 5025, 400 Maryland Ave. S W, W ashington, DC, 20202 - 2800.**Data Collection Instrument**

Page 59 

### Data Collection Instrument **IT/Telecommunications Training Performance Measure**  **TO BE COMPLETED BY PROGRAM STAFF** I D ( o p t i o n a l )

____________ IT/Telecom Training Session D a t e training was provided : __________ D a t e t h i s fo r m wa s re c e i v e d :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Please answer the following question about the training you participated in prov ided by ( insert name of statewide AT program or its subcontractor)

. Weneed this inform ation to provide high - quality services and to m eet the requirem ents for receiving federal funding. Wh at do you anticipate will be the prim ary outcom e of your participa tion in this training on I nformation T echnology/Telecommunications Access ? **(Please mark only one answer that best represents the primary outcome** **.)**

_____ IT and telecommunications (web, software, etc.) procurem ent or developm ent policies, procedures, or practices will be im proved or better im plem ented to ensure accessibility

_____ Training will be developed / im plem ented to ensure accessibility of websites, software or other IT and t elecommunications (web, software, etc.)

_____ Outcom e is u nknown at thi s time. Paperwork Burden Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information is 1820 - 0572 . The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the i nformation collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to U.S. Department of Education, W ashington DC, 20202. If you have any comments or concerns regarding the st atus of your individual submission of this form, write directly to Mr. Robert Groenendaal , Rehabilitation Services Administration, U.S. Department of Education, Potomac Center Plaza, Room 5025, 400 Maryland Ave. S W, W ashington, DC, 20202 - 2800.**Survey Instrument Consumer Satisfaction** 

Page 60 

### Surve **y Inst**  **rument Customer Satisfaction**  **TO BE COMPLETED BY AT PROGRAM STAFF** ID (optional) __________ S e r v i c e s p ro v i d e d : **Device demonstration Device loan**  **“State financing” services —**  **including financial loan, assistance in accessing funds for AT devices/services, assistance in obtainin**  **g AT devices and services at reduced cost or free, or other related services**  **Device reu se** 

**— received an AT device through a device exchange** **, reassignment/** 

**re furbish**  **or repair or open -** **ended loan program**  D a t e s e r v i c e d e l i ve ry wa s c o m pleted: __________ D a t e t h i s fo rm wa s re c e i ve d :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1. Wh ich of the following best reflects your level of satisfaction with the services you received? **(Check one.)** _____ Highly satisfied _____ Satisfied _____ Satisfied somewhat

_____ Not at all satisfied Paperwork Burden Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information is 1820 - 0572 . The time required to complete this information collection is estimated to average 2 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete an d review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to U.S. Department of Education, W ashington DC, 20202. If you have any comments or concerns re garding the status of your individual submission of this form, write directly to Mr. Robert Groenendaal , Rehabilitation Services Administration, U.S. Department of Education, Potomac Center Plaza, Room 5025, 400 Maryland Ave. S W, W ashington, DC, 20202 - 2800

.